California’s emergency medical services (EMS) system is in critical condition, most industry analysts would agree. In many parts of the state, hospital emergency department (ED) overcrowding, patients leaving without being treated, ambulance diversion, and paramedic downtimes caused by ED saturation have reached crisis levels.

When asked by a critical member of the media if we were prepared to handle a September 11 type of medical crisis in Los Angeles, Virginia Hastings, former Los Angeles County EMS Agency director, said, “Can we handle a terrorist attack? Don’t be ridiculous! We can’t handle a routine Friday night in Los Angeles!”

Critics like Hastings also agree that a fundamental redesign of the system is needed. This redesign should be undertaken with all deliberate speed, and all participants should commit to a Rawlsian “veil of ignorance,” tabula rasa approach to this effort. With this in mind, one part of the redesign might include creating and using freestanding EDs.

Assuming that protocols could be developed to ensure patient safety and positive medical outcomes, the policy question to be answered becomes: Should paramedics be allowed to transport emergency patients to medical facilities other than licensed general acute care hospitals that have ED permits?

Although freestanding EDs existed more than 40 years ago in Los Angeles and elsewhere, the newer models are barely a year old. Many more are on the drawing boards. Except for a concept under development in Texas, no two appear to be identical–in terms of licensure, ownership, affiliations, services offered, breadth and scope of emergency treatment, ambulance traffic, etc.

The challenge is to see if any of these niche players can develop faster, cheaper and better models. The freestanding model has long been explored for rural areas. In her study, “A Limited-Service Rural Hospital Model: The Freestanding Emergency Department” (Journal of Rural Health, 1999), Sharon Avery concluded that even with best-case scenarios concerning reimbursement, these models cannot remain financially stable without subsidy from the community and/or affiliations with other health care facilities.

According to the Centers for Disease Control and Prevention, U.S. hospital ED visits increased more than 20 percent in the last decade. The current average wait time is three hours, with more than half of patients waiting two to six hours. These conditions are much worse in Los Angeles County.

Many interrelated factors influence the high utilization problem, which also contribute to the increasing ambulance diversion rates. For example:

• Increased demand for ED services. Population growth has spurred demand in some areas. Other factors include growth in the uninsured and in the numbers of patients with no regular source of primary care. Less restrictive managed care policies also have cracked open the ED door.
• A shortage of on-call specialists and a managed care-driven need to avoid inpatient admission have lengthened ED stays, exacerbating overcrowding. Patients are now observed longer in the ED if there’s a chance that an admission can be avoided.
• The nursing shortage and nurse staffing ratios in California are limiting the number of staffed beds for transfer, further causing ED congestion.

Freestanding EDs do not exist in California at this time, and licensing provisions do not exist for them. Reportedly, the state Department of Health Services (DHS) is vehemently opposed to their development. According to DHS Licensure and Certification, one cannot have an ED without eight basic services–medical, nursing, laboratory, radiology, pharmacy, food service, anesthesia and surgery–which essentially constitute a hospital.

There were attempts to change the landscape. After Scripps Health closed a rural hospital in East San Diego County several years ago because of the seismic safety mandate, elected officials serving the area wanted to replace the hospital with access to emergency services in the area. Assemblyman Jay La Suer (R-San Diego) asked Sharp Healthcare to consider sponsoring a freestanding ED. Sharp officials studied the issue and found the concept unsupportable in that market. Meanwhile, Scripps has made major capital improvements and expansions to its existing East County facility.

Assemblyman La Suer introduced a spot bill in 2003, but the bill was not fleshed out so approval was not sought. Two bills were introduced in the current legislative session by other legislators from Los Angeles, but neither received any serious consideration.

The development of new models of emergency care seems to be part of the niche movement to create “specialty hospitals.” But instead of necessarily skimming off profitable business, these models seem to have emerged from the dissatisfaction over waiting times at traditional hospital EDs. In some cases, urgent care centers are attempting to expand their services to attract “the walking wounded” from EDs. In other cases, hospitals and health systems have attempted to capture market share by opening freestanding EDs in high growth and/or underserved areas.

Both for-profit and not-for-profit systems seem to be investigating these new models. If emergency service capacity continues to be stressed in many of our urban communities, perhaps one or more versions of the freestanding ED model should be explored.

What do you think?